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Abstract

In 2003, academic staff members at The University of the West Indies Faculty of
Medical Sciences St Augustine Trinidad and Tobago combined their expertise to
make strides in Alzheimer's and Dementia research in Trinidad and Tobago. Dr.
Nelleen Baboolal, Dr. Gershwin Davis and Professor Amanda McRae began developing
a project that has produced significant results by examining not only the
epidemiology of dementia, but the associated risk factors; caregiver burden and
ultimately establishing biomarkers for the disease. This review is an account of
our results from a decade of dementia research and how they are contributing
toward mitigating the dementia tsunami in Trinidad and Tobago.

INTRODUCTION

The Republic of Trinidad and Tobago is a twin island state located at the
southernmost tip of the Caribbean archipelago. Its multi-ethnic population of
approximately 1.3 million consists of East Indian 40.3%; African 39.6%; mixed 18.4%;
and 1.7% belong to other ethnic groups.1 Ethnic differences have been observed in many important complex
chronic illnesses and acute infections. There is an established predominance of
early-onset diabetes mellitus in the South Asian population and a higher prevalence
and severity of hypertension in African citizens.2 There is an increase in metabolic syndrome across all ages
of the population. Furthermore and highly significant, is that Trinidad and Tobago
is an ageing population. At present, the elderly population of Trinidad and Tobago
stands at 13 percent or 177, 676 persons over the age of 60 years.1 This figure is expected to increase
to 17.7% by 2025. In essence, this population resides amid an arsenal of risk
factors currently considered to potentiate cognitive decline. As the population of
the Trinidad and Tobago ages there is a need to prepare the policy makers for what
could be considered a cognitive deficit tsunami. One can ask: are we ready for the
social and physical changes that accompany aging?

For many, dementia remains a stigma. Consequently, the elderly may have a tendency
not to report early symptoms of memory loss. This can even extend to family members
who may be reluctant to accept or report that an elderly relative is displaying
cognitive decline. As the population ages it is essential to prepare the population
for the road ahead.

There have been some improvements in this direction with the establishment of eight
senior activity centers and organizations such as the Senior Achievers, Golden Years
and the Trinidad and Tobago Association for Retired Persons and the Alzheimer's
Association of Trinidad and Tobago. These social organizations are essential for
mental stimulation and to decrease loneliness.

Epidemiological data is fundamental to optimize planning of services and
policy.3,4 The absence of functional and reliable data
collection is obscuring the reality of dementia in this region. There has been a
gross underestimation of the number of cases of dementia in the country, as many
patients with dementia live at home they are not being accounted for.

Furthermore, there is growing concern about caregivers. Many caregivers have no
knowledge about the clinical features of the disorder. Therefore they are
ill-prepared to cope with the behavioral changes which accompany the progression of
dementia. This group needs to be educated about the frustration and exhaustion
encountered by caring for an elderly relative with dementia. Many caregivers are
elderly themselves.

Delaying the onset of Alzheimer's disease is a high priority for any given
population. Identifying strategies to slow down the progression of AD as well as
other aged-related cognitive disorders has become a collective world-wide mission.
Progress has been made to decipher areas which have the potential to lower the risk
of AD. Simple interventions including diet, education, exercise, and increasing
cognitive activity are among several factors recently considered ways of reducing
the risk of Alzheimer's disease. Thus, it is important for a given population to
identify risk factors which may be pertinent to their region and environment,
thereby allowing interventions to slow down the onset of dementia.

Trinidadians are at great risk for dementia. Firstly, there is a high prevalence of
diseases which are risk factors for dementia.2 Secondly, the World Health Organization has estimated that
the prevalence of Dementia in the Caribbean and Latin America is the highest in the
world.5

What is being done in Trinidad and Tobago to mitigate the dementia tsunami? To this
end, the present review will provide an account of the efforts of three academic
staff members at the University of the West Indies at the Faculty of Medical
Sciences to help prepare the population and policy makers for this tsunami.

RESEARCH TEAM

One could consider that this is a result of being at the right place at the right
time. The University of the West Indies promotes research and specifically
encourages faculty members to form research clusters. This was the case for Dr.
Nelleen Baboolal, Senior Lecturer in Psychiatry, Dr. Gershwin Davis, Senior Lecturer
in Chemical Pathology, and Professor Amanda McRae, Professor of Human Anatomy who
had individually conducted dementia research. We met and decided to pool our
expertise in order to make strides in Alzheimer's and Dementia research in Trinidad
and Tobago.

For the last decade we have consistently held research meetings on Wednesdays. Our
dedication and commitment to dementia research has indeed been very rewarding. We
began developing a four-stage project that could yield breakthrough results by
examining not only the epidemiology of Dementia, but the associated risk factors;
caregiver burden and ultimately establishing biomarkers for the disease. This is a
collaborative effort not on a specific project but on the theme of Alzheimer disease
and Dementia and Mild Cognitive Impairment (MCI). To that end, we established and
incorporated Dementia Awareness and Research of Trinidad and Tobago (DARTT) which is
a voluntary non-profit organization which aims to educate the population, promote
brain health, diagnose afflicted persons, support patients, families and caregivers,
conduct research on Alzheimer's disease and establish the prevalence of dementia and
its economic burden.

In 2003, a very successful memory clinic was established at a tertiary teaching
hospital. This provided the infrastructure for both clinical and basic research.
Patients were seen and clinical evaluations, blood and neuro-radio imaging
investigations and assessment of caregivers were done.

Another successful approach from our collaboration has been outreach. We have all
participated in several local TV programs aimed at promoting dementia research and
extending awareness of dementia to the general population.

Realizing that several of our research projects would need age-matched control
subjects we made contact with organizations such as the Senior Achievers and the
Golden Years. Both of these organizations are composed of dynamic seniors aged 60
and above. We were invited to their monthly meetings to address issues related to
dementia and its awareness. They all agreed to take the Mini-Mental State Exam
(MMSE)6 and donate blood
samples. We arranged a day at each organization and administered the MMSE. Blood
samples were taken on a different day. Another organization where we have had a
conspicuous presence is the Alzheimer's Association of Trinidad and Tobago (AATT)
where we interacted with a monthly support group for caregivers. In addition to
caregivers at Dr. Baboolal's memory clinic, we have also administered caregiver
questionnaires to those attending the AATT. Furthermore, we have played active roles
in events organized by the AATT during Alzheimer's awareness month in September.

In 2005, we also launched a MPhil/PhD Neuroscience degree at the University of the
West Indies, the first such degree program in the English-speaking Caribbean. Our
first PhD Neuroscientist graduated in 2014.

Additionally, between 2011 and 2013 the research of two graduate students, who
completed the Masters in Public Heath at the University of the West Indies, was
supervised by Dr. Baboolal. Their research projects examined "The Plight of the
Caregiver: A Study of the Burden Placed upon Caregivers of Patients with Dementia in
Trinidad" and "The Prevalence of depression among the Elderly who attend Senior
Activity Centres in Trinidad".

From the very outset of our collaboration, Dr. Baboolal considered that one of the
most important achievements from our group would be to establish the prevalence of
dementia and its economic impact in Trinidad and Tobago. Determining a central
figure such as the prevalence of dementia in Trinidad and Tobago is critical because
for the first time, it will provide the Government, and anyone else who wants to
know, with a picture of how common dementia is and the socio-economic cost that
comes with it. Results will also have enormous transformative implications for
policy, as they will highlight the economic reasons for investing in dementia.
Though we realized how essential it was to establish the nationwide prevalence of
dementia and its economic impact in Trinidad and Tobago, organizing this project,
including funding, took several years and in fact the project actually began in
2012. While we were preparing for the nationwide prevalence study, we conducted a
prevalence of dementia investigation in persons attending senior activity centers,
those in nursing homes, and persons collecting welfare checks.

Professor. R. Stewart of the Institute of Psychiatry, King's College, London has been
instrumental in guiding us with the preparations of the prevalence of dementia
study. He has conducted several workshops and will analyze the data.

In view of the high prevalence of diabetics in Trinidad and Tobago,2 we also investigated cognitive
function in type 2 diabetic patients. This collaboration benefited from the
expertise of Professor S. Teelucksingh of The University of the West Indies.

Our collaborative efforts have generated several publications, book chapters,
workshops and conference presentations at international conferences, including the
International Conference on Alzheimer Disease, Vas Cog, American Association of
Clinical Chemistry Conference and Caribbean Health Research Conference.

Our major research accomplishments include:

Biomarkers, cognitive assessment in diabetic patients, caregiver burden, prevalence
of dementia in three different settings, and the nationwide prevalence and economic
impact of dementia in Trinidad and Tobago. The sections below provide a synopsis of
results obtained from some of these various research themes.

BIOMARKERS

One key facet of the project of our group is developing a serum screening biomarker
for the disease that could introduce a paradigm shift in the way we approach the
healthcare maintenance of the elderly. This is due to the fact that a serum marker
would provide a universal means to differentiate Alzheimer's Disease (AD) from other
dementias, as well as establish early detection of the disorder.

The Trinidadian population may have a raised risk for dementia because hypertension,
diabetes and cerebrovascular disease are common.2

Based on the high prevalence of the above disorders we chose to investigate factors
which could predict or assist in discriminating types of dementias in our population
from healthy seniors.7

We selected the amino acid homocysteine (tHcy), C-reactive protein (CRP) and serum
sialic. Elevated circulating levels of homocysteine are an independent risk factor
for stroke.8 Furthermore, elevated
levels of tHcy have been linked to cognitive decline.8,9 CRP is
considered to have a link to cardiovascular disorders and has been investigated in
relationship to the development of certain dementias.10 Serum sialic acid is a potent cardiovascular and
renal risk factor as it is increased in cerebrovascular disease and in patients with
micro- and macro-vascular complications of diabetes.11 In view of the relationship of sialic acid to
disorders considered risk factors for dementia, it may also be a predictor of
cognitive decline.

The investigation included 51 healthy elderly individuals who were members of a
seniors group plus 27 persons with dementias of the Alzheimer's type (AD), persons
with Alzheimer's disease or persons with pure vascular dementia (VaD). The MMSE was
administered and all patients were subjected to interview, physical examination and
neurological examination. The clinical/biochemical characteristics of both groups
were compared.

Plasma tHcy was determined on the Abbot AxSym using FPIA. Serum CRP concentrations
were measured using the Tina-Quant sCRP (Latex) high sensitive immunoturbidimetric
assay on the Roche/ Hitachi 912 Automatic Analyzer. Serum sialic acid was measured
by spectrophotometric assay using standard chemicals and reagents. For the dementia
patients, the main clinical diagnoses were AD, 18 (67%) and VaD, 9 (33%).7

When the controls were compared with all patients as a group, the MMSE and sialic
acid differed significantly, with MMSE scores being higher and sialic acid levels
lower.in controls. Patients with AD had significant differences in the MMSE scores
and sialic acid scores, but not for tHcy and CRP values when compared with controls.
In patients with VaD however, significant differences were obtained for both MMSE
scores and tHcy but not for sialic acid or CRP.

Several research studies have shown that the concentration of sialic acid in serum is
elevated in pathological states when there is damage to tissue, tissue proliferation
and inflammation The latter has in recent times reemerged as an important aspect of
the pathogenesis of Alzheimer disease.12 Our findings suggest that elevations in serum sialic acid
levels could be related to AD pathology. In this regard, it is of interest that a
recent study13 has demonstrated
that reduction in sialic acid protects PC 12 cells from B amyloid toxicity. From a
speculative point of view, the elevated levels of sialic acid may reflect an
increase in the deposition of B amyloid. Further studies are necessary to elucidate
the relationship between elevated sialic acid levels and ongoing AD pathology.

The finding that sialic acid levels were significantly higher in patients with AD
compared to controls and not different with respect to VaD is unlike the results for
tHcy, where notable differences were found between VaD and controls. This suggests
that there may be different mechanisms at work in the pathogenesis of the two
conditions.7

We have also identified another biomarker which appears to have diagnostic potential.
Previous studies have demonstrated that the cerebrospinal fluid (CSF) from AD
patients contains an antibody directed against microglia (MgAbs).14 The rapidly expanding field of
neuroinflammation has revealed that immunocompetent microglia play an early role in
the events leading to AD pathology.15 It should be remembered that a biomarker is a substance such as
an antibody or protein, which is usually present in either the cerebrospinal fluid
or blood. According to the criteria of the Consensus Report of the Working Group on
Molecular and Biochemical Markers of AD, an ideal biomarker should: be able to
detect a fundamental feature of AD neuropathology; and be validated in
neuropathologically-confirmed AD cases; be precise (able to detect AD early in its
course and distinguish it from other dementias); reliable; non-invasive; simple to
perform; and inexpensive.16 Thus,
it appears reasonable to propose that MgAbs could be a potential biomarker for
AD.

This antibody has shown in both clinically14 and neuropathologically confirmed AD cases17 to be present at a greater
frequency in the CSF compared to other dementias. Among patients in Trinidad and
Tobago, we further demonstrated that serum MgAbs can distinguish AD from healthy
age-matched controls.18 There was
no significant difference between the presence of MgAb in VaD patients compared to
controls.18

For us, an exciting milestone was reached in 2008, after conducting a workshop
entitled "Biomarkers for Dementia. Is there a role?" at the American Association of
Clinical Chemistry Conference in Washington DC. This attracted the attention of a
major UK-based diagnostic company. Subsequently, collaboration developed between
this company and the UWI to further the development of MgAbs as a diagnostic
biomarker for Alzheimer's disease.

This collaboration was pursued. We identified major histocompatibility complex 1
(MHCI) as the microglial surface antigen to which autoantibodies are directed in AD
patients. ELISAs were established using two distinct forms of MHCI as the antigen.
One form was HLA.A*0201, the most commonly expressed form of MHCI in humans, whilst
rat RT1.Al was also used to provide a more direct comparison with the rat
brain cross-sections previously employed for immunocytochemistry. Data was analyzed
by constructing receiver operator characteristic (ROC) curves. When the
cerebrospinal fluid (CSF) samples from the cohort of 20 patients with Alzheimer's
disease and the 20 individuals without Alzheimer's disease were tested on the newly
developed ELISA platform there was a clear and statistically significant association
between the presence of anti-MHC1 antibodies and the presence of Alzheimer's
disease. Using RT1.A as the antigen in the ELISA, the area under the curve (AUC) was
0.756 (p=0.0004) and when using HLA-A*0201 as the antigen the AUC was 0.705
(p=0.0071). The ROC curve analysis suggested that for the CSF we have a new ELISA
test that is at best good at distinguishing AD patients from controls (Figure 1). This test should be studied not only
in patients with Alzheimer's disease but also in other groups of patients such as
those classified as MCI. Further work is in progress to establish an ELISA test for
serum MgAbs.

COGNITIVE TESTING IN DIABETES MELLITUS PATIENTS

The elevated prevalence of diabetes mellitus in Trinidadian citizens is an indication
that a large part of the population is at risk of developing dementia. It has been
established that patients with diabetes have increased deposition and decreased
clearance of amyloid,19 as well as
increased incidence of hypoglycemia and hyperglycemia which contributes to cognitive
impairment. Patients with a diagnosis of diabetes have nearly double the risk of
developing both dementia and mild cognitive impairment compared to non-diabetics in
the elderly population.20 In view
of the link between diabetes mellitus and cognitive decline, we considered that it
would be relevant to investigate cognitive function in patients with diabetes
mellitus in Trinidad and Tobago. There were 96 patients with type 2 diabetes
mellitus and 87 age-matched non-diabetic controls in this study. Demographic data
was obtained from both diabetic patients and healthy age-matched controls.

In order to determine normal cognitive function, MCI, or dementia the following
tests: Addenbrooke`s Cognitive Examination Revised (ACE-R), MMSE (Mini-Mental State
Exam), Color trails-1, Color trails-2, Picture-Number Matching, Word Recall and
Digit Span Forward and Backward were administered to both patients and controls.

Of all these tests, only performance on the ACE-R - a brief cognitive screening
instrument sensitive to early stages of dementia- was significantly different when
comparing persons with diabetes to controls.

These findings suggest that the ACE-R could be a useful screening test in primary
care for detecting the presence of early cognitive dysfunction in diabetics. The
MMSE was not sensitive enough to pick up mild cognitive impairment in Diabetic
patients.

CAREGIVING IN TRINIDAD AND TOBAGO

Dementia and cognitive impairment are the leading chronic disease contributors to
disability, and particularly dependence, among older people worldwide. The need for
support from a caregiver often starts early in the dementia journey, intensifies as
the illness progresses over time, and continues until death.21 Caregivers include family,
friends, as well as community and paid caregivers who may or may not be family. The
World Alzheimer Report 2013 reveals the global Alzheimer's epidemic is creating a
shortage of caregivers and lack of support for family members.

Unpaid care for persons with dementia is provided by family, friends and community,
and care is generally referred to as 'informal' care. Paid care is referred to as
'formal' care. Family caregivers and paid caregivers share much in common. They all
carry out difficult, demanding and socially useful roles, with minimal training and
preparation. In Trinidad and Tobago, a significant number of persons suffering from
dementia are cared for at home by an informal caregiver. Caring for a person with AD
and other dementias is associated with significant risk to the caregiver's health
and well-being.22

The term "caregiver burden" is used to describe the physical, emotional and financial
cost of providing care.23 The
Zarit Burden Interview (ZBI) is a standardized, validated, reliable tool for
assessment of the burden of caregivers for dementia patients.

There has been no assessment of caregiver burden in Trinidad and Tobago. Thus, we
administered the ZBI to caregivers to evaluate the degree of burden in caregivers of
dementia patients in a Trinidadian population. The ZBI was developed by Zarit and
co-workers in 198524 and comprises
a 22-item questionnaire with a five-item response set ranging from "never" to
"nearly always" graded on a scale from 0 to 4, according to the presence or
intensity of an affirmative response. Based on the total score, individuals were
classified as having little or no burden (0-20), mild to moderate burden (21-40),
moderate to severe burden (41 to 60), or severe burden (61-88). The questions refer
to the caregiver/patient relationship and evaluate the caregiver's health status,
psychological well-being, finances, and social life. The caregiver burden is
evaluated by means of the total score obtained from the sum total of questions. We
also included an evaluation of the possible risk factors associated with higher
burden. The effects of different factors including patient and caregiver age,
gender, years of education, relationship between the patient and caregiver as well
as the patient's symptom duration and degree of cognitive impairment were
investigated.

Informed consent was obtained from all caregivers and informed consent by proxy was
obtained for the investigation of patient characteristics. Seventy-five patients
diagnosed with dementia along with their caregivers were included in the study.
Patients were diagnosed using the DSM IV TR,25 the MMSE,6
clinical evaluations, laboratory investigations and brain CT or MRI. Demographic
characteristics of patients and their caregivers were recorded

The GHQ-28 was administered to all caregivers. It contains 28 items that, through
factor analysis, have been divided into four sub-scales. The GHQ-28 is the most
well-known and popular version of the GHQ. It is used to detect psychiatric disorder
in the general population and within community or non-psychiatric clinical settings
such as primary care or general medical out-patients. It assesses the respondent's
current state and asks if that differs from his or her usual state. It is therefore
sensitive to short-term psychiatric disorders but not to long-standing attributes of
the respondent.

Data revealed that there were 56 female (74.7%) and 19 male (25.3%) patients with 36
(48%) more than 79 years of age. Patient ages ranged from 59 to 94 years, mean 77.6
years, S.D. 8.3. Thirty-six (48%) patients were of African descent, 13 (17.3%) of
East Indian descent and 26 (34.6%) other ethnicities. Thirty (40%) were married, 32
(42.7%) widowed, 6 (8%) were single and 5 (6.7%) divorced. Duration of symptoms of
dementia was 0.08 to 14 years, mean 4.3 years, S.D. 3.5.

Most caregivers were females 61 (81.3%) and 48 (64%). Caregiver ages ranged from 27
to 86 years, mean 57.3, s.d. 15.2. The majority of the caregivers were offspring 32
(42.7%) and spouses 18 (24%). Forty-one (54.7%) caregivers were married and 35
(46.7%) had secondary school education.

The ZBI scores ranged from 0 to 63 with a mean of 22.7, S.D.14.7. and 41 (55%)
overall had some degree of burden. According to the Zarit Buren Interview scores,
45% experienced little or no burden, 43% experienced mild to moderate burden, 11%
moderate to severe burden and 1% severe burden. The GHQ Scores were >47 in 49.3%
of caregivers (p=0.01).

The preponderance of females with dementia in this study is significant and in
keeping with international studies.26-28 Persons who were
not of East Indian or African descent were described as belonging to a minority
ethnic group. It is therefore surprising that in our study there were only 13
(17.3%) persons of East Indian descent with dementia since, according to the 2011
Census, persons of East Indian descent comprised 35.4%, African descent 34.2%, mixed
persons comprised 22.8%, and other ethnic groups 1.4%.2 Whether this is due to lower numbers of East Indian
patients with dementia is a finding that requires exploration in future studies.

Caregiver burden was significantly associated with the patient being male (p=0.03)
and the patient belonging to a minority ethnic group (p=0.07). Our study answers the
question 'who are the caregivers?'. Akin to other reports29,30 we too
have found that over 80% of caregivers are women, more specifically middle-aged
women. It is notable that the majority of these women are adult children and
spouses. Though we have found that the degree of burden with respect to the Zarit
Burden Interview score did not differ from other caregivers, this is a group that is
at increased risk for stress-related medical conditions since they form the majority
of the caregivers. Although other studies report higher caregiver burden in female
caregivers,31 there was no
correlation between gender of the caregiver and burden in the present study.

Our study found no significant correlation between relationship of the caregiver to
the patient, cohabiting status of the caregiver, marital status of the caregiver,
educational level of the caregiver and occupation of the caregiver.

The GHQ Scores, a measure of psychiatric morbidity, were >47 in 49.3% of
caregivers. Higher caregiver burden scores using the ZBI were associated with higher
caregiver GHQ scores, a finding that supports previous studies.32 Research has shown that caregivers
of demented patients are nearly twice as likely to have symptoms of depression
compared with caregivers of non-demented people. As such, caregivers should be
advised to protect their personal time, watch out for symptoms of depression such as
crying more, sleeping/eating more or less than usual and lack of interest in usual
activities.

Our study found that 45% of the caregivers experienced little or no burden. This
might reflect the easy acceptance of dementia for the elderly in the Trinidadian
population where taking part of the elderly is a normal intergenerational
experience. In Trinidad, it is not culturally usual to institutionalize aged family
members (demented or otherwise) and the elderly are commonly a part of normal living
in many households. More than half of the caregivers (55%) had moderate to severe
burden

Another issue that this study hints at is the impact of this unpaid care giving on
the financial health of these individuals who, in there middle age, have other
responsibilities including taking care of their own families. This is an area that
would need follow-up studies. This is especially important since the average
duration of dementia in our study was 4.4 years.

In the absence of state and private agencies to support the elderly, the familial
care networks have been and continue to be the main source of support for seniors in
Trinidad and Tobago.33 Our
findings underscore the global impact of caring for a person with dementia and
support the need for caregiver support, education, training and access to medical
care.

THE PREVALENCE AND ECONOMIC COST OF DEMENTIA IN TRINIDAD AND TOBAGO

In 2012, we launched the Prevalence of Dementia and its Socio-economic Burden study
in Trinidad and Tobago.

The project is a collaboration between the Dementia Awareness Research of Trinidad
& Tobago (DARTT), Faculty of Medical Science and the Centre for Health
Economics, Faculty of Social Sciences, The University of the West Indies.

The fundamental purpose of this project is to determine the prevalence of dementia in
persons aged 60 and above in all municipalities in Trinidad and Tobago. This study
will also determine the associated cost and implications for the family and
caregivers, health care system and economy of Trinidad and Tobago.

The prevalence study will use validated 10/66 interview protocols34,35 together with a socioeconomic questionnaire generated by
the Center of Health Economics unit of The University of the West Indies.

The protocols of the key research instrument, the 10/66, have successfully
established the prevalence of dementia in a number of countries including Cuba,
Mexico, Peru, Venezuela, the Dominican Republic, India and China.35,36 With the use of an extended 10/66 protocol and
collaboration with Professor Robert Stewart (Institute of Psychiatry, King's College
London) a founding member of the 10/66 research group, it is certain that our result
can be compared with data from other countries. This would have a significant effect
on the interpretation of results as to future trends and impact of dementia in our
local setting.

Dementia will be diagnosed using an abbreviated and recently validated version of the
10/66 assessment schedule.35 The
component measures will consist of the Community Screening Instrument for Dementia
(CSI-D), the CERAD 10-word list recall task, and the EURO-D depression scale.

Standard practice in 10/66 surveys to date has been to recruit 2000 participants aged
65 years and over per site.34,35

Our survey in Trinidad and Tobago will improve on the usual 10/66 design in two
ways:

It will be the first 10/66-style survey of a national population (rather than
a geographic catchment);

It will be the first such survey to adopt age-stratified sampling. The latter
approach is feasible in Trinidad and Tobago because of the recent national
census which provides the opportunity to sample within age ranges (something
not possible for most countries) and is particularly valuable for a disorder
such as dementia whose prevalence increases exponentially with age
(approximately doubling with every 5-year increase in age after 65).

The proposed sample will be recruited in the following strata: 500 participants aged
60-69 years, 500 aged 70-79, 500 aged 80-89, 500 aged 90+, randomly sampled
throughout all municipalities in Trinidad and Tobago.

To ensure that our door-to-door 10/66 surveys are conducted in a similar manner as
those performed in the other countries, Professor Robert Stewart, our International
consultant, conducted a training workshop for the 30 selected field workers.

The field work has now been completed and the data is being analyzed so that
determination of the prevalence of dementia and its socioeconomic burden in Trinidad
is imminent.

The impacts of this study are as follows:

Firstly, this study is the first of its kind in Trinidad and Tobago and will
allow our policymakers to comprehend both the current prevalence and impact
of dementia.

Impact of the socioeconomic findings from our study. It is anticipated that
the findings of this study will build awareness of the full cost of dementia
(including some cost elements that may not have been as obvious to those not
directly impacted by dementia). This study will detail the needs of the
individual and households affected by dementia with a view to enhancing the
welfare and wellbeing of such individuals and households

To raise public awareness about dementia which in turn should: reduce stigmas
surrounding the disorder, encourage early diagnosis, help family and
caregivers cope with the disorder, lead to the adoption of healthier life
styles which could postpone the onset of dementia.

One of the anticipated impacts of our study is that policy makers will make
dementia a national priority by adopting and implementing a National
Dementia Plan.

Conclusion. The research presented in the this review is the result of
the efforts of three staff members of the Faculty of Medical Sciences at the
University of the West Indies who pooled their expertise to advance knowledge about
dementia. It has been indeed a rewarding journey and the fruits of our research are
beginning to be revealed. For one, we are also very pleased to have been asked to be
members of a committee that will produce the National Dementia plan for Trinidad and
Tobago. Secondly, we consider that through our various types of outreach we have
been increasing dementia awareness in Trinidad and Tobago.

It is our goal, as we continue with our research, that it makes a difference for
those affected by the disorder either directly or indirectly, that it allows policy
makers to give a high priority to dementia research, and that systems will be put
into place to decrease caregiver burden. All of these should indeed mitigate the
dementia tsunami in Trinidad and Tobago.

Acknowledgments

We would like to express our appreciation to the Alzheimer's Association of Trinidad
and Tobago and all persons who volunteered to participate in this research including
patients, caregivers, members of the Senior Achievers and Golden Years. We would
also like to extend our appreciation to all of our research assistants who carried
out much of the work presented in this review. Funding was provided by several
grants from the University of the West Indies Campus Publication Research fund and a
generous grant from the Government of Trinidad and Tobago.

Footnotes

Disclosure: The authors report no conflicts of interest.

REFERENCES

1. Republic of Trinidad and Tobago Ministry of Planning and the
Economy. Central Statistical Office . population and housing census preliminary count.pdf. 2011.

16. Consensus report of the Working Group on: "Molecular and Biochemical
Markers of Alzheimer's Disease" The Ronald and Nancy Reagan Research Institute of the Alzheimer's
Association and the National Institute on Aging Working
Group. Neurobiol Aging. 1998;19:109–116.[PubMed]

33. Ministry of the People and Social Development Division of
Ageing); National report Republic of Trinidad and Tobago at the third Regional
Intergovernmental Conference on Ageing in Costa Rica; 2012.

34. Prince M. Methodological issues for population-based research into dementia
in developing countries. A position paper from the 10/66 Dementia Research
Group. Int J Geriatr Psychiatry. 2000;15:21–30.[PubMed]